Terry Williams

My goals finish school start my own business. Look to advance my career goals.

• We are happy to assist with completing FMLA, Short Term Disability, or Accidental Claims forms. To proceed, we need your authorization to release this information.
• Note:
• Each request requires a separate form submission.
• If you are a caregiver, the patient must complete this form.
• Please allow 7-10 business days for form completion.
• Have you already submitted or dropped off your FMLA or Short Term Disability form to the office?
• Dropped it off at OrthoNebraska Location: A R S P A C E
• Emailed to OrthoNebraska
• Faxed to OrthoNebraska
• Text or Chat to OrthoNebraska
• Is this request for the medical condition of:
• Self (you are the patient)
• Minor (child under 19 years old is the patient)
• Care of a Family Member (this form will need to be completed by the patient)
• Name of the Family Member needing care:
• Relationship to patient:
• Patient Information
• First Name: Terry
• Last Name: Williams
• Date of Birth: 1970-04-01
• Phone: (402) 706-2833
• Address: 3427 Blondo St.
• City: Omaha
• State: NE
• Zip: 68111
• Release of Information
• I authorize the disclosure of my personal health information, including medical records, from OrthoNebraska Hospital and OrthoNebraska Clinic for the purpose of form completion.
• Office/Clinic Notes
• Operative/Procedure Reports
• History and Physical
• Discharge Summary
• Consultation Reports
• Laboratory Reports
• Radiology Reports
• Emergency Room Reports
• Physical/Occupational Therapy Notes
• Treating Provider: Matthew Tingue
• OrthoNebraska.com
• Nebraska Orthopaedic Hospital LLC and OrthoWest, LLC are each operating under the name OrthoNebraska. For more, visit OrthoNebraska.com/legal

• Employer/Third Party (for example, Insurance)
• Name/Organization to receive completed forms and/or pertinent medical records:
• Secure Fax:
• Secure Email:
• Mail Address:
• City:
• State:
• Zip:
• Self (Parent or guardian if patient is a minor)
• Mail to address listed on Patient Information
• By signing this authorization form, I understand that:
• Records disclosed may contain information relating to behavioral/mental health services, treatment of alcohol or drug abuse, sexually transmitted disease, AIDS, HIV, or self-paid services.
• OrthoNebraska will not condition treatment on whether I sign this authorization.
• Requests for copies of medical records may be subject to copying fees.
• I may revoke this authorization at any time by notifying OrthoNebraska Medical Records Department in writing at the address listed at bottom of this form. If I revoke the authorization, it will not have any effect on actions taken prior to receipt of the revocation.
• Unless otherwise revoked, this authorization will expire on the following date/event/condition listed below. If I do not specify an expiration date/event/condition, this authorization will expire one (1) year from the date signed.
• I understand that the information used and/or disclosed according to this authorization may no longer be protected by federal privacy law (also known as HIPAA), and the recipient of my health information may potentially re-disclose it.
• Expiration Date:
• Signature of Patient or Personal Representative:
• Terry Williams
• Date: 2026-04-15
• Printed Name: Terry Williams
• If Personal Representative of the patient, list your authority or relationship to patient (e.g., parent, legal guardian):
• OrthoNebraska.com
• Nebraska Orthopaedic Hospital LLC and OrthoWest, LLC are each operating under the name OrthoNebraska. For more, visit OrthoNebraska.com/legal

• The employee or provider can submit this form directly to the HR Leave Coordinator at leavecoordinator@nmhs.org or fax a copy to (402) 815-9622. The employee's supervisor does not receive a copy of medical documentation.
• Prior to returning to work, you must provide a Fitness for Duty Certification verifying whether you are able to return to work, if you have any job-related restrictions and the duration of any restrictions. You must return this completed Fitness for Duty Certification form to Human Resources as requested, or your return to work may be delayed or denied under the FMLA.
• Please have your healthcare provider complete this form and return it to Human Resources by:
• Essential functions of the employee's position attached
• Section I: For Completion by the Employee
• I give permission to my health care provider to supply Human Resources with the requested data for the purpose of determining whether I am fit to return to work after my FMLA leave. In addition, I authorize my health care provider to provide to Human Resources data regarding my fitness to return to work for the purposes of clarifying or authenticating information previously provided, or to provide missing information. I understand that the data I provide will be accessed by authorized personnel whose jobs reasonably require access, such as FMLA leave coordinators or claims management specialists.
• Employee Name: Terry Williams
• Employee ID Number: E47659
• Signature - Employee
• Date: 2026-04-11
• Section II: For Completion by the Health Care Provider
• The employee is required to provide a complete and sufficient Fitness for Duty Certification, completed by his or her health care provider, prior to returning to work from FMLA leave. This certification is being sought only with regard to the particular health condition that caused the employee's need for FMLA leave. If a list of the essential functions of the employee's position is included with this form, please consider these essential functions as you review the employee's fitness for duty.
• Date of medical examination: 2026-02-10
• I certify that, with regard to the particular health condition that caused the employee's need for FMLA leave, the employee is fit for duty and able to resume work.
• Full/unrestricted duty, effective: 2026-02-10 - 2026-05-28
• Modified duty, effective:
• The employee is not released to return to work: No work Beginning 2026-05-28
• I hereby certify that I have examined the employee named above, and declare that the statements made in this Fitness for Duty Certification are true and correct.
• Health Care Provider's Name: Austin Penny APRN
• Health Care Provider's Signature: Matthew Taylor
• Health Care Provider's Business Address: 2725 S. 144th St. Omaha 68144
• Phone: 402-609-3000
• GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008 DISCLOSURE
• The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to the request for information. "Genetic information" as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

• Please provide your contact information, complete all relevant parts of this Section, and sign the form below. Your patient has requested leave under the FMLA. The FMLA allows an employer to require that the employee submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to the serious health condition of the employee. For FMLA purposes, a "serious health condition" means an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by a health care provider. Additional space is provided at the end of the form should you need it. Please be sure to sign the form on the last page.
• Health Care Provider's Name: Dr. Matt Tingue, Austin Penny APRN
• Health Care Provider's Business Address: 2725 S. 144th St. Omaha 68144
• Type of Practice / Medical Specialty: Orthopedics / Orthopedic Surgeon
• Telephone: 402-609-3000
• Fax: 402-609-3888
• E-mail: N/A
• Part A: Medical Information
• Limit your response to the medical condition(s) for which the employee is seeking FMLA leave. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be specific as you can; terms such as "lifetime," "unknown," or "indeterminate" may not be sufficient to determine FMLA coverage. Do not provide information about genetic test, genetic services, or the manifestation of diseases or disorder in the employee's family members.
• After completing Part A, complete Part B to provide information about the amount of leave needed. Note: For FMLA purposes, "incapacity" means the inability to work, attend school, or perform regular activities due to the condition, treatment of the condition, or recovery from the condition.
• State the approximate date the condition started or will start: 2026-05-28
• Provide your best estimate of how long the condition lasted or will last: 8 weeks
• Was medication, other than over-the-counter medication, prescribed? No
• Dates you treated the patient for the condition: 2026-02-10
• Check the applicable boxes below. For all boxes checked, the amount of leave needed must be provided in Part B.
• Inpatient Care: The patient (has been / is expected to be) admitted for an overnight stay in a hospital, hospice, or residential medical care facility on the following date(s):
• Incapacity plus Treatment: Due to the condition, the patient (has / is expected to be) incapacitated for more than three consecutive, full calendar days from 2026-05-28 to 2026-07-28
• The patient (was / will be) seen on the following date(s): 2026-06-19, 2026-07-12
• Pregnancy: The condition is pregnancy. Expected delivery date:
• Chronic Conditions: Due to the condition, it is medically necessary for the patient have treatment visits at least twice per year due to the condition? No
• Permanent or Long Term Conditions: Due to the condition, incapacity is permanent or long term and requires the continuing supervision of a health care provider (even if active treatment is not being provided).
• Conditions Requiring Multiple Treatments: Due to the condition it is medically necessary for the patient to receive multiple treatments.
• None of the above: If none of the above condition(s) were checked, no additional information is needed. Go to page 3 and sign and date the form.
• Use the information provided by the employer in Section I to answer this question. If the employer fails to provide a list of the employee's essential job functions or a job description, answer these questions based upon the employee's own description of his/her job functions. Is the employee unable to perform any of his/her job functions due to the condition? No. If so, identify the job functions the employee is unable to perform:

• The employee or provider can submit this form directly to the HR Leave Coordinator at leavecoordinator@nmhs.org or fax a copy to (402) 815-9622. The employee's supervisor does not receive a copy of medical documentation.
• Section I - Employee Information
• Employee Name: Terry Williams
• Employee ID Number: E47659
• Employer Name: Methodist Health System
• Date: 2026-04-11
• This medical certification must be returned by:
• Employee's Job Title: Anes Tech
• Employee's Regular Work Schedule: 40 Hours
• Employee's personal email address for communication: wterry100@gmail.com
• Employee's Essential Job Functions: Please see attached job description
• Section II - For Completion by the Employee
• Please complete Section II before giving this form to your medical provider. The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. Failure to provide calendar days to return this form.
• Reason for Family Medical Leave:
• Injury to my left knee torn meniscus
• Need scope to repair.
• If my reason for leave is pregnancy, I'm requesting weeks of leave.
• Signature - Employee
• Print - Employee
• Date: 2026-04-14

• Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):
• None
• For the medical condition(s) checked in Part A, complete all that apply. Several questions seek a response as to the frequency or duration of a condition, treatment, etc. Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient. Be specific as you can; terms such as "lifetime," "unknown," "indeterminate" may not be sufficient to determine FMLA coverage.
• Due to the condition, the patient (had / will have) planned medical treatment(s) (scheduled medical visits) on the following date(s): 2026-06-19
• Due to the condition, the patient (was / will be) referred to other health care provider(s) for evaluation or treatment(s). State the nature of such treatments: Physical Therapy
• Provide your best estimate of the beginning date 2026-06-11 and end date 2026-07-12 for the treatment(s), including any period(s) of recovery.
• Due to the condition, it is medically necessary for the employee to work a reduced schedule. Provide your best estimate of the reduced schedule the employee is able to work, hours per day, per week from through.
• Due to the condition, the patient (was / is / will be) incapacitated for a continuous period of time, including any time for treatment(s) and/or recovery. Provide your best estimate of the beginning date 2026-05-28 and end date 2026-07-28 for the period of incapacity.
• Due to the condition, it (was / is / will be) medically necessary for the employee to be absent from work on an intermittent basis (periodically), including any episodes of incapacity, episodic flare-ups. Provide your best estimate of how often (frequency) and how long (duration) the episodes of incapacity will likely last. Over the next 6 months, episodes of incapacity are estimated to occur times per (day / week / month) and are likely to last approximately (hours / days) per episode.
• Additional Information:
• Signature - Health Care Provider
• Date: 2026-04-14